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INFECTION OF BONE AND JOINT
ธนพจน จันทรนุม
ภาควิชาออรโธปดิกส โรงพยาบาลรามาธิบดี
OBJECTIVE
• Make diagnosis and treatment in bone and joint sepsis
li i f di d• Prevent complications from disease and treatment
• Use and update on new evidence base
CONTENT
Osteomyelitis
Septic ArthritisSeptic Arthritis
Case
• Male
• 3 year‐old
• Thai
• Normal labour Hx and development
• Adequate immunization
• Ulceration with discharge from right forearm 10 days
Case
• Febrile 38.50
• Cry when touch his forearm
• Rest like “paralysis” => Pseudoparalysis
••Debridement was done with tissue and Debridement was done with tissue and pus culture => S. aureuspus culture => S. aureus
••Repeat XRepeat X--ray in ray in 10 10 days laterdays later
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OSTEOMYELITIS
Classification
Pathogenesis
Diagnosis
Treatment
Signs & Symptoms Prognosis
OSTEOMYELITIS :CLINICAL CLASSIFICATION
• Acute (within 14 days of onset)
b ( d f )• Sub acute (> 14 days of symptoms)
• Chronic ( > 28 days, sequestra)
ACUTE OSTEOMYELITIS : DERMOGRAPHY
• Decreased incidence
• Peak incidence in childhood ( Gilmour 5 6 yrs Trueta 10 11 yrs )Gilmour 5‐6 yrs, Trueta 10‐11 yrs )
• Male : Female = 2.5 ‐ 4 : 1
• Monostotic & Lower extrem. = 90%
• Most Common Location = Long bone ( METAPHYSIS )
OSTEOMYELITIS
• Morbidity ~ 6 %
‐ Delay Rx , Inadequate RxDelay Rx , Inadequate Rx
‐ Failure of identifying organism
OSTEOMYELITIS : METAPHYSIS , WHY?
• Vascular loop Theory
• Immature Phagocyte Theory (Rang 1969 , Ogden 1975)
• Injury Theory (Morrisy & Haynes 1989)
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PATHOPHYSIOLOGY
• Bacteria lodge
• Thrombosis
• Infection spread on least resistanceleast resistance
• Down the medullary canal, through the metaphyseal cortex
Course of Metaphyseal infection
• Expansion, temponade to vessel, destroy cortex
• Periosteal new bone “Periosteal new bone Involucrum”
• Dead bone “Sequestrum”• Rupture of periosteum
Osteomyelitis:Pathology
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Trueta (1959):Pattern of blood supply of long bone
Metaphysis is Intraarticular structure in .......joints.
• ShoulderElb• Elbow
• Hip• Ankle
Acute Hemato. Osteomyelitis : Clinical Features
Early acute
• 2/3 ‐‐>Febrile
• Avoid using the i li
Late acute
• Febrile(4‐7days)
• Obviously sick,sepsis extremity,limps, pseudoparalysis
• localize tenderness, swelling
esp. Neonates
• Sympathetic effusion(knee)
Acute Hemato. Osteomyelitis : Lab.& Routine Investigation
• CBC, ESR, CRP
• Blood C/S +50%
• X‐ray changes
• Aspiration
No abscess ‐>ATB,observe
after 7 days,look for new bone, mottling
Abscess
‐>ATB, surgical drainage
Osteomyelitis:X‐ray Osteomyelitis:X‐ray
• 5% of radiographs were abnormal initially
• 33%were abnormal by 1 week
• 90%were abnormal by 4 weeks
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Osteomyelitis:X‐ray Acute osteomyelitis:Special studies
• Bone scan:
– Technetium
– Gallium
I di– Indium
• CT / MRI
• Ultrasound
Bone Scan
Early, sensitive, show Early, sensitive, show extension & multiple lesionsextension & multiple lesions
NonNon--specific, only in centerspecific, only in center
Technetium Bone Scan
• Uncommonly needed
• If diagnosis is equivocal
If result would alter therapy
• Three phase: Sensitivity‐0.9 to 0.95
Specificity‐ 0.75 to 0.95
• Needle aspiration dose not affect for 72 hours
MRI
• Most accurate imaging study
• Sensitivity‐ 0.97, Specificity ‐ 0.92
• T1 ‐ low to intermediate signal
T2 ‐ high signal intensity
• Rarely needed in acute osteomyelitis
• Reserve for ‐ pre‐op planning of chronic
‐ atypical cases: spine,pelvis
Ultrasound (US)
Current knowledge / Consensus
• US detects changes sooner than X‐ray
• US can localize subperiosteal abscess
• Stages
‐ earliest sign ‐ deep soft tissue swelling
‐ periosteal elevation,fluid underneath
‐ periosteal abscess
• May detect concurrent septic arthritis
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DIFFERENTIAL DIAGNOSISof osteomyelitis
• Trauma
• Tumors – Osteosarcoma
• Cellulitis
• Tropical Pyomyositis
• Necrotizing fasciitis
• LeukemiaOsteosarcoma
– Ewing’s sarcoma
– Metastasis neuroblastoma
– Eosinophilic granuloma
• Leukemia
• Bone Infarction
Acute osteomyelitis: Diff. Diagnosis
• Cellulitis
• Pyomyositis
• OsteosarcomaOsteosarcoma
• Ewing’ sarcoma
• Leukemia
• Sickle cell with bone infarction
ETIOLOGY
• Neonate– Strephylococcus group B
– Staphylococcus aureus
– Gram Negative
• Infant & Preschool– Staphylococcus aureus
– Strephylococcus group A
– Haemophilus influenzae
• Children to Adult– Staphylococcus aureus
– Vary
Etiology:Common Bacterial organism
1. Neonate : Staphylococcus aureus
Strep. Gr. B
Gm. negative
2. Infant & : Staph. aureus, H.influenzae
Preschool
3.Children : Staph. aureus
Acute osteomyelitis : Management
• Aspiration
• Conservative
• Surgical
Acute osteomyelitis:Aspiration
• 16‐18 gauge needle inserted at area of maximal tenderness
Pus Aspirate, Gm stain OR
hild iNo Pus Young child into
metaphysis C/S
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Acute Hemato. Osteomyelitis:Conservative treatment
• Admission
• Intravenous fluidIntravenous fluid
• Bed rest, splinting, traction
• Antibiotics
ACUTE OSTEOMYELITIS : ANTIBIOTIC THERAPY
• Initial with intravenous route
• Dose – maximum in range e.g. 50‐100 mg/kg/d
• Criteria for switching to oral medication ‐ vary
in each institute
Osteomyelitis: Antibitic
HematogenousHematogenous--empiric treatmentempiric treatment
EtiologiesEtiologies Primary RxPrimary Rx Alternative RxAlternative Rx CommentsComments
Newborn (0Newborn (0--4 mos.)4 mos.) S. aureus, GmS. aureus, Gm--neg neg bacilli, Gr. B strepbacilli, Gr. B strep
Anti staph Pen Anti staph Pen + Ceph 3+ Ceph 3
Vanco + Ceph 3Vanco + Ceph 3 Rx minimum 21 dRx minimum 21 d
Children (>4 mos.)Children (>4 mos.) S. aureus, Gr. A strep, S. aureus, Gr. A strep, coliforms rare coliforms rare
Anti staph Pen Anti staph Pen /Ceph 1 /Ceph 1 +/+/ Ceph 3Ceph 3
Vanco/ClindaVanco/Clinda IV then oral until IV then oral until 33--6 wks.6 wks.
+/+/-- Ceph 3Ceph 3
Adult (>21yrs)Adult (>21yrs) S. aureus, +variesS. aureus, +varies Anti staph Pen 1Anti staph Pen 1--2 2 gm q6 h IV gm q6 h IV /Cefazolin 1/Cefazolin 1--2 2 gm IV q8 hgm IV q8 h
Vanco 1 gm q12h Vanco 1 gm q12h IVIV
Empiric RxEmpiric Rx
AdultAdult--Drug abuse, dialysisDrug abuse, dialysis
S. aureus, P. aeruginosaS. aureus, P. aeruginosa Anti staph Pen Anti staph Pen + CIP+ CIP
Vanco + CIPVanco + CIP
AdultAdult--compromisecompromise
Salmonella sp.Salmonella sp. FluoroquinoloneFluoroquinolone Ceph 3Ceph 3
Splint & Traction
ACUTE OSTEOMYELITIS : INDICATION FOR OPEN DRAINAGE
1. Present with abscess
2. Present with osteomyelitis adjacent to the
joint – hip, shoulder, ankle & elbow
3. No improvement after 48 hrs. of
conservative treatment
4. To rule out malignancy
OSTEOMYELITIS :SURGICAL TREATMENT
• Incise periosteum
• Avoid additional elevation of periosteum
• Suction / copious irrigation of pus
• Tiny drill hole in metaphysis ??• Tiny drill hole in metaphysis, ??
• Small abscess ‐ close over drain
• Large abscess ‐ leave open
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ORAL THERAPY : NELSON CRITERIA
• Prerequisites
‐ adequate response to I.V. Rx
‐ able to swallow medication
‐ compliance assured‐stable home situation p
‐ established etiologic agent
‐ lab to perform bactericidal titers (1:8)
• Dosage‐ 2 ‐3 times usual oral dosage
‐ 45‐60 min. after suspension
‐ 11/2‐2 hrs. after capsule
ORAL THERAPY: GREEN, U. Missouri/ Columbia
• Early acute
* I.V. therapy for 2 to 5 days
* If response, discharge on oral ATB
without obtaining titerswithout obtaining titers
• Late acute
* Surgical drainage, almost universal
* I.V. therapy for 7 to 14 days* Switch to P.O. therapy (Nelson )
Mornitoring Response of Treatment
Early ‐ fever, constitutinal symptoms,tenderness
Intermediate C ‐ reactive protein better than ESRCRP normal ESR normal
Osteomyelitis only 6 + 3 days 17 + 10 daysOsteo+septic jt. 11 + 7 days 25 + 12 days
Late(6weeks)persistent tenderness ‐ need more therapyX‐ray, ESR
COMPLICATIONS OF OSTEOMYELITIS
Concomitant Septic Arthritis– Typically, present like septic arthritis
With younger age (<
Distant seedingDistant seedingpneumonia,pericarditispneumonia,pericarditisPathological fracturePathological fractureChronic osteomyelitisChronic osteomyelitis
– With younger age (< 10 months)
– Longer duration, prior Rx for oteitis media,etc
– Sequelae common :‐ hip, shoulder
Growth disturbanceGrowth disturbanceMorbidity/mortalityMorbidity/mortality
SUBACUTEOSTEOMYELITIS CHRONIC OSTEOMYLITIS
• Clinical Manifestation
– Sinus Tract–Bone Pain–Acute Inflammation
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CHRONIC OSTEOMYLITIS CHRONIC OSTEOMYLITIS
CHRONIC OSTEOMYLITIS Chronic Osteomyelitis
• Factor for Predisposing– Degree of bone necrosis
– Nutrition
Age– Age
– Infecting organism
– Comorbidity
– Drug abuse
Posttraumatic Osteomyelitis
• Factors that contribute– Presence of hypotension
– Inadequate debridement of the fracture site
Malnutrition– Malnutrition
– Alcoholism
– Smoking
SEPTIC ARTHRITIS
•Hematogenous spread
•Direct inoculation•Contiguous spreadContiguous spread
• Shoulder ‐ proximal humerus
• Elbow ‐ radial neck• Hip ‐ proximal femur
• Ankle ‐ distal fibula
• Infection from surgical wound
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SEPTIC ARTHRITIS: Dx
• History and physical examinations
• Classic triad – fever , swelling and tenderness (effusion)
• Limitation of joint motion
• Resting position e.g. Hip‐ abduction, ext. rotation, flexion
• Laboratory studies
• CBC ‐ PMN in acute infection
• ESR ‐ occur at 3‐5 d , return to normal 3 wk.
• CRP ‐ within 6 hr. , return to normal 1 wk.
• Synovial fluid analysis
• Microbiologic studies
Joint Fluid Analysis
Disease WBC NeutrophilNormal <200 <25%Trauma <5000 <25%Trauma 5000 25%Toxic Synovitis 5000-15,000 <25%RF 10,000-15,000 50%JRA 15,000-80,000 75%Septic >80,000 >75%
Pathology
• Hyperemia
• Infiltrate c PMN
• Cell death , degrade cartilage B i l i l i• Bacterial toxin , proteolytic enzymes
• Destruction of cartilage• 4 ‐ 6 d after infection
• Complete in 4 wk.
• Joint dislocation / subluxation / osteomyelitis
Pathophysiology
Bacterial inoculationBacterial inoculation MacrophageMacrophage
Inflammatory ResponseInflammatory Response
Metalloproteases EnzymeMetalloproteases Enzyme
ILIL--11
Collagen and Cartilage damageCollagen and Cartilage damage
ChondrocyteChondrocyte
Site of Aspiration
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Treatment
• 3 essential principles• Joint must be adequately drained• ATB must be given to diminish the systemic effects of sepsis
• Joint must be rested in a stable positionJo t ust be ested a stab e pos t o
• Initial ATB ‐ base on age and risk factor• S. aureus .‐ requiring 4 ‐ 6 wk • Neisseria, Streptococcus, H. influenza
• Rapid response to ATB , short duration ( < 2 wk.)
• Drainage should be perform for all septic arthritis
SEPTIC ARTHRITIS: Complications
• Pathologic dislocation
• Osteomyelitis
• Persistent infection• Persistent infection
• AVN
• Destruction of epiphysis
• SCFE
Prognosis
• Duration before diagnosis
• Extreme age
• Virulence of organisms
• Adequate surgical treatments
THE END